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Permit
n CITY OF TIGARD PLUMBING PERMIT ' ` °= COMMUNITY DEVELOPMENT Permit #: PLM2009 -00287 F 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 10/13/2009 , ,.. R , 9 Parcel: 2S102CB02800 Jurisdiction: TIG Site address: 9975 SW FREWING ST Subdivision: Lot: Project: MASSIH OFFICE BUILDING Project Description: Install (9) lays and (9) water closets. 10/13/09, removing (1) lay and (1) water closet from scope of work. Owner: FEES KAMELIA MASSIH Quantity Description Date Amount 1831 SW DICKINSON LANE PORTLAND, OR 97219 9 ea Lavatories 10/13/2009 $225.18 PHONE: 9 ea Water Closet 10/13/2009 $225.18 1 12% State Surcharge - 10/13/2009 $54.04 Plumbing Contractor: SELBY PLUMBING INC. 2373 NW 185TH HILLSBORO, OR 97124 PHONE: 503 - 730 -3437 FAX: Type of Use: COM Class of Work: ALT Type of Const: Occupancy Grp: Stories: Total $504.40 Required Items and Reports (Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules or direct - ions to Si • : • Ilin• 503.246.6699 or 1.800.332.2344. Is ued By: I / / ( Permitt• • Signature: ` 11 � , Call 503.639.4175 by 7:00 a.m. for an inspection that . ' mess day. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. . :1 . " City of Tigard TIGARD Memorandum To: Amy Lawson • From: Dianna Howse . Re: PLM2009 -00287 Date: December 2, 2011 On October 29, 2009, Kathy Gende informed me that a check from the contractor for the above permit was returned for NSF. A few weeks later, the same contractor requested a refund for a portion of the permit fees that he paid and a refund check #00101651, dated 11/12/09 in the amount of $56.04 from the city was routed to me for distribution. We held the refund check in the file until the contractor reimbursed the city for the NSF check, however I have no record of the city being reimbursed so we held onto the refund check. I found this refund check in the file and I am returning it to you for processing. Thank you and please let me know if you have any questions. • *123000220* 10/19/2009 000000937001163 0- This is a LEGAL COPY of your o BILL GIBBS DBA 1 783 check. You can use it the same way ti SELBY PLUMBING ENTERPRISES 20-710211 you would use the original check. 2373 NW 165TH 1425 LAI pHl 509 . R73o -34 36 GON 97121 f /il 376 p ▪ r 0H. .0.34 7 V ( RETURN REASON A o ru NSF - NOT SUFFICIENT '-q RWTOTHE • � / ••''� $ S 2 � / FUNDS mmER. ._•. Y � l R rl �� r .: f � " - i,- . m ;� 7 ,a ru O w N 9 T D � _ elocrL o BANIOLWEST Iv ti ll� 00000208 • • PLM2009 -00287 - Status History gXiobe. /Z /z / .. Status Status Date Action By Comment Hold 11/20/2009 Dianna Howse Void 11/20/2009 Dianna Howse Scope of work changed. Refund 100% of permit fees per Building Official. Hold 10/29/2009 Dianna Howse Hold pending reimbursement of NSF check by contractor. Please direct contractor to speak with Kathy Gende. Remove hold when you receive a copy of the receipt from Kathy. Issued 10/13/2009 Debbie Adamski Ready to Issue 10/13/2009 Debbie Adamski In Review 10/13/2009 Debbie Adamski ° City of Tigard TIGARD Accela Refund Request This form is used for refund requests of land use, engineering and building application fees. Receipts, documentation and the Request for Permit Action or Refiurd form (if applicable) must be attached to this form. Refund requests are due to Accela System Administrator by Friday at 5:00 PM for processing each Monday. Accounts Payable will route refund checks to Accela System Administrator for distribution. Please allow 1 -2 weeks for processing. PAYABLE TO: Bill Gibbs dba Selby Plumbing DATE: 11/5/09 2373 NW 185t #425 Hillsboro, OR 97124 REQUESTED BY: Dianna Howse DEB TRANSACTION INFORMATION: Receipt #: 175598 Case #: PLM2009 -00287 Date: 10/13/09 Address /Parcel: 9975 SW Frewing St. Pay Method: Check Project Name: Massih Office Building EXPLANATION: Scope of work changed - refund 100% of permit fees for (1) lay and (1) water closet plus 12% state surcharge. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: [BUILD] Permit Fee Example: 245 - 0000 - 432000 $ Amount Plumbing permit fees 2300000 -43101 $50.04 12% State Surcharge 1003100 -24001 6.00 TOTAL REFUND: $56.04 APPROVALS: If under $500 Professional Staff If under $7,500 Division Manager • O 1 MAA,,1 If under $22,500 Department Manager If under $50,000 City Manager If over $50,000 Local Contract Review Board FOR ACCELA SYSTEM ADMINISTRATION USE ONLY Refund Request Reviewed: Date: ///57,0z; By: -- Case Refund Processed: Date: By: . i i I: \ Building \Refunds \RefundRequest.doc 04/13/09 J r :5 e ° Community Development r 1 c. n �i Request for Permit Action TO: CITY OF TIGARD Building Division Services Coordinator 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor % City Staff (check one) REFUND OR Name: � INVOICE TO: (Business or Individual) --61 LL C Ig6S "l bil d Et_11i y kuMg11. 6 1 1JC Mailing Address: a 37 3 IJ W I Q 5 it. 426- 5 City /State /Zip: N / 1-1.6420 OZ. q7 , AV Phone No.: ! 3 - -3438 . PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ❑ CANCEL PERMIT APPLICATION. ❑ REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: Act) 9. ooas7 Site Address or Parcel #: q9 5 f/212.0 ',Jai - Project Name: H q�d ft- PaL . Subdivision Name: Lot #: EXPLANATION: — Pro3 1 ,3 C 1 Pacrili kooH o ko l f 0PF oG (.0 n . 1 /C. -- Pau, cev1 ► J a c r 1 c, AL. h9t2K OAriUoHfe;e t11 et a t007o Dr 646 (l)1 --A%1 (.. • " / •LDPrrb2. C1-05ar6025•ox) t reeTt t.da.r RQC0f. `l (4.eO) Signature: I. ∎ _ , _. _" L ' Date: /0/3/0 9 Print Name: Dt t t 4. !4a/Wti tv Refund Policy 1. The Director or Building Official may authorize the refund of: a) any fee which was erroneously paid or collected. b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended. c) not more than 80% of the land use application fee for issued permits. d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended. e) not more than 80% of the building permit fcc for issued permits prior to any inspection requests. 2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds. FOR OFFICE USE ONLY Rte to Sys Admin: Date 0 AI 01 y Rte to Bldg Admin: Date By Refund Processed: Date By Invoice Processed: Date By Permit Canceled: Date By Parcel Tag Added: Date By Receipt # /1559k Date /Q //. /0 f Method / ek Amount $ I:\ Building \Forms \RegPermitAction.doc Re107/26/07 r CITY OF TIGARD RECEIPT I G 8 . 1312 SW Hall Blvd., Tigard OR 97223 .\ 503.639.4171 \ ) TIGARD Receipt Number: 175598 - 10/13/2009 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2009 -00287 Lavatories • 2300000 -43101 $225.18 PLM2009 -00287 Water Closet 2300000 -43101 $225.18 PLM2009 -00287 12% State Surcharge - Plumbing 1003100 -24001 $54.04 Total: $504.40 PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 1783 DADAMSKI 10/13/2009 $504.40 Payor: Bill Gibbs DBA Selby Plumbing Enterprises Total Payments: $504.40 X03 230 -.3q37 Balance Due: $0.00 • • • Page 1 of 1 CAP ID: PLM2009 -00267 $ Pay S • Apply f I Refund ® Void Q Generate Receipt WJ Fund Transfer ? Help + Go To ■gs - Inspections (1) Organiraton Ovmer (1) Parcel (3) Payment Payment History Professionals (2) Related CAPS Total Invoice Amount $504.40 Terminal S: Total Payment $504.40 Cashier ID: OHOWSE Total Balance: $0.00 Date: 11/20/2009 — Amount Plot Applied: moo Invoices Invoice A Amount Paid In Full Balance 1i^ =i7 $504.40 Y $0.00 Transactions Transaction Transactions Method Receipt # hot Applied Amount Status Trust Account ID Date Code Payment Check 50.00 $504.40 Paid 10/13/: CAP ID: PLM2009 -00287 CD Menu Cl Search - e Help + Go To ■ry CAP Activities (0) Activity Summary (4) Address (1) Addtl Into App Specific Into App Specific Info Tables Status Statts'nfe Acton By Cerrment Und;aterl Date Updated by Hc'd 11/20/2009 Dianna Howse 11/20/2009 DHOWSE • c d 11/20/2009 Dianna Howse Scope of work changed. Refund 100... 11/20/2009 DHOWSE H 1 10/29/2009 Dianna Howse Hold pending reimbursement of NSF ... 10/29/2009 DHOV/SE =� =.d 10/13/2009 Debbie Ada... 10/13/2009 DADAMSKI . " ct :n ISC■we 10/13/2009 Debbie Ada... 10/13/2009 DADAMSKI :a Sr- •,.e:, 10/13/2009 Debbie Ada... 10/13/2009 DADAMSKI } Plumbing Permit Applic iun' g p ril Building Fixtures F OR OFFICE .USE ONLY . g I City of Tigard OCT -_ J 2009 Date/By / /II I / / 6 / Q Permit No.: , G e ,,��'03j2 *7 V 13125 SW Hall Blvd., Tigard, OR 97223 Plan Review IN 0 ; Phone: 503.639.4171 Fax: 501;19 6t1_ Date/By: ther Permit No : Inspection Line: 503.639.4175 t 7` TIGARD y p n i n Date Ready /By: s: �} El See Page 2 for TIGARD Internet: www.tigard - or.gov BU,LDlI G DIV ISI ON Notified/Method: 1/,. Supplemental Information TYPE OF WORK FEE* SCHEDULE 1 New construction CI Demolition For special information use checklist • Description I Qty. I Ea. I Total % Addition/alteration /replacement ❑ Other: New l - 2- family dwellings (includes 100 ft. for each utility connection) CATEGORY OF CONSTRUCTION SFR (I) bath 312.70 CI 1- and 2- family dwelling JZ1 Commercial /industrial SFR (2) bath 437.78 SFR (3) bath 500.32 El Accessory building ❑ Multi- family Each additional bath/kitchen 25.02 ❑ Master builder ❑ Other: Fire sprinkler ( sq. ft.) Page 2 JOB SITE INFORMATION AND LOCATION Site utilities: Job site address: G G 7 C �� £' t Catch basin or area drain 18.76 _ Drywell, leach line, or trench drain 18.76 City /State /ZIP: ) 1 ; C O J Footing drain (no. linear ft.: ) Page 2 Suite/bldg. /apt. no.: Project name: `7/1 55 / g1 )5 07 Manufactured home utilities 50.03 Cross street/directions to job site: y7 1 Manholes 18.76 Rain drain connector 18.76 Sanitary sewer (no. linear ft.: ) Page 2 Storm sewer (no. linear ft.: ) Page 2 Water service (no. linear ft.: ) Page 2 Subdivision: I Lot no.: Fixture or item: Tax map /parcel no.: ?.S! O a /,3 -Q 3,,e, p Backtlow preventer 31.27 DESCRIPTION OF WORK Backwater valve 12.51 Clothes washer 25.02 Dishwasher 25.02 Drinking fountain 25.02 Ejectors /sump 25.02 PROPERTY OWNER I ❑ TENANT Expansion tank 12.51 J�/� /' Fixture /sewer cap 25.02 Name: K� / 4 2 , aa/ / J S Floor drain/floor sink/hub 25.02 Address: /c 3 a� /Ci_l SOif L7 . . ( Garbage disposal 25.02 © City /State /ZIP: /?L ) 9/e --2oZ / Hose bib 25.02 Phone: ( ) Fax: ( ) Ice maker 12.51 ❑ APPLICANT ❑ CONTACT PERSON Interceptor /grease trap 25.02 Business name: Medical gas (value: $ ) Page 2 Primer 12.51 Contact name: Roof drain (commercial) 12.51 Address: Sink/basin/lavatory q 25.02 City /State /ZIP: Solar units (potable water) 62.54 Phone: ( ) Fax: : ( ) Tub /shower /shower pan 12.51 E -mail: Urinal 25.02 Water closet ! 25.02 CONTRACTOR / /� k'11-1 Water heater 37.52 Business name: Ste/ / COC (/� l �!? � Water piping/DWV 56.29 Address: al 3 -7 3 4) } / g5-- # ct a Other: 25.02 City /State /ZIP: / 7 ((S /J a &e, / d c / a ��i ( Subtotal Phone: (sod - 2 3,-3 y 3 F( Fax: (56 )6'5x-- 11 ( 1� Minimum permit fee: $72.50 � � . CCB Lic.: / 3 �U� .2/17//, Plumbing Lic. no.:/47W 2a2,6"-- Plan review (25% of permit fee) e' State surcharge (12% of permit fee) 51. 0 Authorized signature: C_i r� TOTAL PERMIT FEE *9) /D ! �( / Print name: f / - ( Date / 3 /0 5 This permit application expires if a permit is not obtained within 180 days 6._ 6._ L! / ( / after it has been accepted as complete. *Fee methodology set by Tri- County Building Industry Service Board. 1. \Building'Permits\PLM1J- PermitApp.doc 10/01/09 440- 4616T(10 /02 /COM/WEB) Plumbing Permit Application - City of Tigard Page 2 - Supplemental Information Fee Schedule: Residential Fire Suppression Systems: Site Utilities Qty. Fee (ea) Total Square Footage: Permit Fee: Footing drain - U' 100' 50.03 0 to 2,000 $121.90 Footing drain - each additional 100' 37.52 2,001 to 3,600 $169.69 3,601 to 7,200 $233.20 Sewer - 1st 100' 62.54 7,201 and greater $327.54 Sewer - each additional 100' 37.52 Water Service - 1st 100' 62.54 Medical Gas Systems: Water Service - each additional 100' 37.52 Valuation: Permit Fee: Storm & Rain Drain - 1st 100' 62.54 $1.00 to $5,000.00 Minimum fee $72.50 Storm & Rain Drain - each additional 100' 37.52 $5,001.00 to $10,000.00 $72.50 for the first $5,000.00 and $1.52 for Other Inspections or Fees Qty. Fee (ea) Total each additional $100.00 or fraction thereof, to P and including $10,000.00. Inspection of existing plumbing or for $10,001.00 to $25,000.00 $148.50 for the first $10,000.00 and $1.54 for which no fee is specifically indicated 90.00/hr each additional $100.00 or fraction thereof, to (minimum charge - 1/2 hour) and including $25,000.00. Inspections outside of normal business 90.00/hr $25,001.00 to $50,000.00 $379.50 for the first $25,000.00 and $1.45 for hours (minimum charge - 2 hours) each additional $100.00 or fraction thereof, to Reinspection Fees 90.00/hr and including $50,000.00. Additional plan review for revisions 90.00/hr $50,001.00 and up $742.00 for the first $50,000.00 and $1.20 for (minimum charge - 1/2 hour) each additional $100.00 or fraction thereof. Subtotal: Commercial Fixture Work: Are you capping, adding or replacing fixtures? If "yes ", Plan Review for Plumbing Installations please indicate work performed by fixture. Failure to Plan review is required for any of the following. accurately report fixtures could result in increased sewer fees * . Please check all that apply. Quantity_ by (Fixture) Work Performed ❑ Any new commercial building with water service 2" and Fixture Type: Replace greater, except systems designed and stamped by licensed Previous Capped Added Existing engineer. Baptistry/Font Bath - Tub /Shower ❑ New exterior plumbing site utilities for any complex structure as defined in OAR918- 780 -0040. - Jacuzzi /Whirlpool Car Wash Each Stall El Medical gas and vacuum systems for health care facilities. Drive Thru ❑ Any multipurpose fire sprinkler system. Cuspidor /Water Aspirator ❑ Any complex structure as defined in OAR918- 780 -0040. Dishwasher -Commercial Submit 2 sets of plans with any of the above. - Domestic Drinking Fountain Eye Wash Isometric or Riser Diagram Floor Drain/sink - 2" ❑ Isometric or riser diagram is required for new buildings that meet the qualifications above. - 4" Car Wash Drain Garbage - Domestic Disposal - Commercial Industrial Comments regarding fixture work: Ice Mach. /Refrig. Drains Oil Separator (Gas Station) Rec. Vehicle Dump Station Shower -Gang -Stall Sink - Bar /Lavatory - Bradley - Commercial *Note: If the fixture work under this permit results in an - Service increase of sewer EDUs, a sewer permit will be issued and Swimming Pool Filter fees assessed for the sewer increase must be paid before the Washer - Clothes Water Extractor plumbing permit can be issued. Water Closet - Toilet Urinal Other Fixtures: I:\ Building \Permits \PLMF- PermitApp.doc 2